Death Cert App 6 1 09 by t2aaSB


									                                         APPLICATION FOR A FLORIDA DEATH RECORD – CUSTOMER USE
                                                                  Sarasota County Health Department – ATTN: Vital Records
                                                                              PO Box 2658 Sarasota, FL 34237

 NAME OF                                                               FIRST                                                                        MIDDLE                                                                            LAST                                                   SUFFIX
         SEX                              DATE OF DEATH ( must be 2000-present)                                               Prior to the year 2000                                                  DATE OF DEATH UNKOWN:                                 GIVE RANGE OF YEARS
                                                                                                                              call 904-359-6900 x9000

                                                                                          COUNTY OF DEATH

                                  IMPORTANT: Read the entire application form before completing. Cause of death is confidential.
 To obtain and use a Florida death record under false or fraudulent purposes is a third-degree felony punishable by the terms and conditions set forth in Florida Statutes.

                                                                         INFORMATION AND INSTRUCTIONS FOR DEATH RECORD APPLICATION
AVAILABILITY: Death registration was not required by state law until 1917 however there are some records on file at the State Office of Vital Statistics dating back to 1877.
                    WITHOUT CAUSE OF DEATH: Any person of legal age (18) may be issued a certified copy of a death record without the cause of death.
                   WITH CAUSE OF DEATH INFORMATION: Death records with the cause of death information may only be issued to the following individuals: 1) the
                   decedent’s spouse or parent; 2) to the decedent’s child, grandchild or sibling, if of legal age; 3) to any person who provides a will, insurance policy or other document
                   that demonstrates his or her interest in the estate of the decedent or 4) to any person who provides documentation that he or she is acting on behalf of any of the above
                   named persons.
                   All requests for certification of a death certificate, that includes the cause of death information, must include signature of the applicant, state his or her qualifying
                   eligibility by providing documents showing relationship or a notarized Affidavit to Release Cause of Death Information (DOH Form # 1959), is available upon
                   request. If you are a funeral director or attorney representing a family member, include your professional license number and the name of the person you are
                   representing along with their relationship to the decedent.
APPLICANT’S SIGNATURE/RELATIONSHIP: Applicant’s signature, relationship, his/her name, residence address & telephone number.

                    Payment: Check or money order payable to SCHD, Cash or Credit Card (cash/CC not accepted in mail)
                                                           Number of Copies                                                                  Number of Copies                                                              Total
                                                           With Cause (ID required)                                                        Without Cause of Death

                    $10.00                                 __________                                                                      __________                                                                      $__________

   Applicant’s Name                                                     FIRST                                                                    MIDDLE                                                                        LAST                                                  SUFFIX

   APPLICANT’S TELEPHONE #                                       APPLICANT’S ADDRESS

APPLICANT’S RELATIONSHIP TO                                      CITY , STATE, ZIP


                              VITAL RECORDS OFFICE USE ONLY                                                                                                                                                                                       DATE

ID TYPE                               ID NUMBER                                                                    EXP.

RECEIPT                                                                                                                                                                                                      SAFETY PAPER CONTROL NUMBERS

DH Form 1961 (New 2/03)

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